Thomas G. Day

Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps.

This report introduces a new method of vaginal reconstruction using a single rectus abdominis myocutaneous flap based distally. Applications of this flap in reconstruction of major abdominal wall and pelvic defects, such as hemipelvectomies, are also described. The flap is designed to carry a paddle of upper abdominal skin on a distally based muscle and vascular pedicle. Advantages of this flap design are (1) the technique is straightforward and rapid, (2) flap viability is reliable, (3) the epigastric skin-fascial donor defect preserves the anterior rectus fascia distal to the linea semicircularis, which prevents hernia, (4) a large arc of rotation is provided, and (5) the epigastric donor site does not interfere with colostomy and urinary conduit stomas in the pelvic exenteration patient. We have done 11 vaginal reconstructions and 9 major pelvic defect reconstructions with this flap during the last 3 1/2 years. In these 20 patients, the only complications were two partial flap losses. No major flap losses or ventral hernias occurred.

Distally based rectus abdominis flap for reconstruction in radical gynecologic procedures

The distally based rectus abdominis myocutaneous flap is an important adjunct to radical pelvic surgery. It can be used to fashion a functional neovagina or to create a patch to cover perineal defects created by exenterative surgery. This report reviews the technical aspects of the creation of this flap and our experience with 22 patients who have undergone this procedure. The flap has been found to be technically easy to create. It is reliable with little tissue loss, and donor site complications are acceptable. Healing is aided by filling the pelvic dead space, thereby decreasing bowel complications, and by bringing a new blood supply into the operative site which has often been heavily irradiated. Operative time is minimized since the procedure requires only unilateral mobilization. Subsequent abdominal surgery has been performed without fascial complications.

Adjuvant chemotherapy in a pregnant patient with endodermal sinus tumor of the ovary

The development of germ cell carcinoma of the ovary during pregnancy is a rare occurrence. Recent advances in chemotherapy have improved significantly the prognosis for patients with early stage disease. Use of cytotoxic agents in pregnancy traditionally has been avoided because of possible teratogenic effects. We describe a pregnant patient who was found to have endodermal sinus tumor of the ovary, stage I, at 13 weeks gestation. She received five courses of adjuvant VAC chemotherapy, beginning with her 17th week of gestation, prior to delivery of a normal infant at term. After an additional seven courses of chemotherapy, a second-look laparotomy revealed no evidence of disease. The infant is developmentally normal at 1 year. A comprehensive review of the literature describing use of chemotherapeutic agents in pregnancy is presented.

Predictive value of CA-125 levels in advanced ovarian cancer

Thirty-eight patients with advanced ovarian cancer were monitored with serial serum CA-125 levels until second-look laparotomy or disease progression. Eleven of 15 patients had normal CA-125 levels but positive findings at second-look operation; two had normal levels despite progression of disease. Normal levels do not reliably predict absence of disease.

Complications in the use of intra-abdominal 32P for ovarian carcinoma.

From 1982 through 1989, 94 patients at the University of Louisville with ovarian neoplasm had abdominal instillation of 15 mCi chromic 32P as part of their management. The timing of the 32P was immediately postoperative in 55 patients and delayed greater than 24 hr in 39 patients. This is an analysis of factors contributing to gastrointestinal (GI) complications. GI complications were graded according to RTOG guidelines. There was a total of 11 GI complications grade 3 or worse for an overall incidence of 12%. Factors analyzed include timing of 32P delivery, age, stage, number of previous surgeries, use of Hyskon at surgery, addition of external beam radiation, and subsequent use of chemotherapy. There were significantly fewer complications when 32P was given on the same day as surgery than when 32P administration was delayed more than 12 hr following surgery (4% vs 21%), P = 0.007. This difference held significance when adjusted for the number of previous surgeries, use of Hyskon, external beam radiation, and stage. None of the other factors had a significant effect on complication rate. There have been no incidences of contamination even though 32P instillation in the immediate post-operative period had increased risk of contamination due to wound leakage or reoperation. In our experience, the delivery of 32P in the immediate postoperative period resulted in a significant reduction in abdominal complications.

Methyl-CCNU, doxorubicin, and cis-diaminedichloroplatinum II in the management of recurrent and metastatic squamous carcinoma of the cervix

Twenty‐three patients with recurrent unresectable carcinoma of the cervix or distant metastasis at initial presentation were treated with methyl‐CCNU (175 mg/m2) and doxorubicin (45 mg/m2) on day 1 and Cis‐diaminedichloroplatinum II (90 mg/m2) on day 22 of a 42‐day treatment cycle. Twenty‐two patients had squamous carcinoma and 1 had adenosquamous carcinoma. There were two complete responses (CR), five partial responses (PR) (>50% tumor reduction, >3‐month duration), four patients with stable disease (<50% reduction, >3‐month duration), and 12 patients who had tumor progression. One CR has been maintained > 28 months, and the other >8 months. Total CR and PR was 7 of 23 (30.4%). Three responses occurred among 15 patients (20%) who had cancer primarily confined to the pelvis, while 4 of 8 patients (50%) with distant metastasis responded. During the initial 2 cycles of chemotherapy, 12 patients had myelosuppression, defined as a leukocytes <3000/mm3, granulocytes <1,000/mm3, or platelets <100,000/mm3. There were no treatment‐related deaths.

Endoarterial pulmonary metastasis of malignant trophoblast associated with a term intrauterine pregnancy

A previously healthy gravida 4, para 3, developed preclampsia and progressive dyspnea at the 37th gestational week and had bilateral pulmonary infiltrates on chest roentgenogram. She delivered a healthy, term, male infant with a normal appearing placenta. Postpartum, her respiratory status gradually worsened. A lung biopsy on the 20th postpartum day revealed intravascular trophoblasts, diffuse arteriolar thrombosis with pulmonary infarction, and subacute interstitial pneumonitis. Combination chemotherapy was instituted, but the patient died from respiratory insufficiency.

Five-year survival following combination radiotherapy and chemotherapy for recurrent mixed mesodermal sarcoma of the ovary

Abstract A patient with a recurrent mixed mesodermal sarcoma of the ovary was treated with pelvic radiation and cytotoxic chemotherapy and remains in remission after 5 years.

Incidence of complications with mini vaginal culpostats in carcinoma of the uterine cervix

Between 1980 and 1987, 298 patients with carcinoma of the uterine cervix were treated at the University of Louisville Department of Radiation Oncology. Of these, 197 (66.1%) were treated for cure by radiotherapy alone: 36 by external beam alone and 161 by external beam and tandem and ovoid applications. The F.I.G.O. staging of the 161 patients was 82 (50.1%) Stage IB, 9 (5.6%) Stage IIA, 40 (24.9%) Stage IIB, and 30 (18.6%) Stage III. The usual treatment was whole pelvis irradiation followed by two intracavitary applications using the Fletcher Suit Applicators of tandem and ovoids in 79/161 patients (49%), a 3-M Mini Applicator (Fletcher Suit Delcos Applicator) in 52/161 patients (32.3%), and a 3-M Mini Applicator with Caps in 30/161 patients (18.6%). The incidence of grade 3-4 gastrointestinal or genitourinary complications as defined by the RTOG was 19.3% (31/161). Various treatment parameters were analyzed to define possible contributing factors. Grade 3-4 complications were seen in 7.6% (6/79) of patients treated with the standard ovoid Fletcher system, 26.9% (14/52) treated with the mini-ovoid system, and 36.6% (11/30) treated with the mini-ovoid system with caps (p = .0006). Although trends were noted, neither the vaginal surface dose (VSD) from the ovoids nor the addition of the external beam dose to the VSD (total vaginal surface dose = TVSD) were significant independent variables (p = 0.19 and = 0.133, respectively). The TVSD was significant when comparisons were made between different ovoid systems (p = 0.05 for less than 12,000 cGy and p = 0.004 for greater than 12,000 cGy). In this study, the 3-M mini applicator was associated with a significant increase in grade 3-4 complications as compared to the Standard Fletcher Suit Applicator.

Occurrence of a thermostable antigen of ovarian carcinoma in normal tissues and secretions.

Thermostable antigen (TA) occurs in ovarian carcinoma and in certain specialized tissues. High titers of TA were found in nineteen of twenty endocervical extracts but not in myometrium, endometrium, or exocervix. TA was present in all of sixteen cervical mucus samples. Antibodies to perchloric acid extract of bronchus showed cross‐reactivity with TA from ovarian carcinoma and cervix. Immunofluorescence with frozen sections revealed TA to be present in the columnar epithelium of ovarian neoplasms, and endocervical glands, in bronchial seromucous glands and in hepatic bile canaliculi. Immunofluorescence and immunodiffusion were used to test for cancer patient antibodies against TA. All sera tested negative. An immunofluorescence inhibition test for circulating TA also tested negative in sera of ovarian and cervical cancer patients.